Structural determinants, responsibilisation and the ethics of vigilance in public health

Vigilance has been proposed as a distinct ethical category within public health, yet its legitimacy depends on more than what is owed to those asked to be vigilant. This article argues that the structural conditions under which vigilance is demanded must themselves be ethically scrutinised. Without proper considerations, vigilance frameworks may risk responsibilisation, where states may neglect their own obligations to address structural determinants, while shifting the burden of managing collective health risks onto individuals. Drawing on the HIV epidemic in sub-Saharan Africa as an illustration, we demonstrate how vigilance without careful design may disproportionately increase the burden of those with the least power, while leaving the unjust conditions that created those burdens unaddressed.